Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone

Use of single-staged transmetatarsal trimmed great toe transfer for reconstruction of a thumb amputation at the carpometacarpal joint

BACKGROUND

Reconstruction for proximal thumb amputation at the carpometacarpal (CMC) joint level is extremely challenging. All thenar muscles are lost and other fingers might be lost or injured. Transmetatarsal trimmed great toe (TGT) transfer may be an option in such cases.

METHODS

Between 2012 and 2018, 11 patients who had amputation of the thumb at the CMC joint level were reconstructed by transmetatarsal TGT transfer in a single stage. There were seven cases in which the right hand was affected and four cases in which the left hand was affected. Three cases involved a contracture scar at the thumb stump and required web space reconstruction. Average follow-up was 33.9 months (range: 12-76 months) RESULTS: All toe transfers survived. The average of static two-point discrimination (S2PD) was 14.6 mm; the average scores of the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) were 18.6 and 73.8, respectively. Two cases did not achieve opposition due to mispositioning of the neothumb. In nine cases achieving opposition, the Kapandji score ranged from 4 to 9, pinch ranged from 3 to 11 lbs, and grip ranged from 15 to 86 lbs. In the donor foot, three patients had neuroma and two had a new callus on the palmar side of the second and third metatarsal heads. The average foot and ankle disability index score was 91.6.

CONCLUSION

Single-staged transmetatarsal TGT transfer is safe and useful for thumb reconstruction at the CMC joint level. This reconstructive method is suitable for manual workers, especially in the developing countries.

A simple approach to thumb amputation reconstruction at metacarpal base with toe transfer, two case reports

•

Reconstruction for thumb amputation at the metacarpal base by toe transfer is challenging.

•

To restore a thumb with normal or near-normal length, the reconstruction plan usually involves a complicated and challenging process either in two stages (stage 1: resolving soft tissue and bone defect; stage 2: toe transfer) or a single stage by using two free flaps (one free soft tissue flap and one toe flap).

•

We accepted the shortened metacarpal length and performed reconstruction in a single stage by trimmed great toe flap, at the level of the metatarsophalangeal joint. The first phalanx of toe flap was fused with the first metacarpal base.

•

The reconstructed thumbs were functional similarly to a thumb amputation group 1 of Campbell-Reid. The tip of the reconstructed thumb looks like that of a normal thumb.

•

With this technique, the reconstruction process could be done more easily and simply in a single stage.

Introduction

Reconstruction for thumb amputation at the metacarpal base by toe transfer is challenging. To restore a thumb with normal or near-normal length, the reconstruction plan usually involves a complicated and challenging process either in two stages (stage 1: resolving soft tissue and bone defect; stage 2: toe transfer) or a single stage by using two free flaps (one free soft tissue flap and one toe flap). However, is it necessary to restore the full length of the thumb for functional and aesthetic achievement?

Presentation of cases

Two male patients (21 and 22 years old) had a thumb amputation at the metacarpal base. We accepted the shortened metacarpal length and performed reconstruction in one stage by trimmed great toe flap, at the level of the metatarsophalangeal joint. The first phalanx of toe flap was fused with the first metacarpal base. On long-term follow-up, both patients were able to return to daily activities, work and had a good cosmesis.

Discussion

With our reconstruction technique, two reconstructed thumbs were functionally similar to a thumb amputation group 1 of Campbell-Reid. Using trimmed great toe flap, the tip of our reconstructed thumbs looks like that of a normal thumb. Both patients were satisfied.

Conclusion

Accepting length shortening, the reconstruction for thumb amputation at the metacarpal base by toe transfer could be done more easily and simply in a single stage.

Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects

It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications.

An Alternative Thumb Reconstruction by Double Microsurgical Transfer From the Great and Second Toe for a Carpometacarpal Amputation

Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe.

Technical Points of 5 Free Vascularized Flaps for the Hand Repairs

In this article, we present the experiences from Chinese microsurgeons on 5 less commonly used free vascularized flaps in hand reconstruction. In many units in China, these flaps have become the mainstays of treatment; they are routinely used for fingertip and thumb reconstruction. Their combined experience has demonstrated the reliability and versatility of these flaps for hand reconstruction, as well as their cosmetic value.

3D Printing Technology in Planning Thumb Reconstructions with Second Toe Transplant

OBJECTIVE

To report preoperative planning using 3D printing to plan thumb reconstructions with second toe transplant.

METHODS

Between December 2013 and October 2015, the thumbs of five patients with grade 3 thumb defects were reconstructed using a wrap-around flap and second toe transplant aided by 3D printing technology. CT scans of hands and feet were analyzed using Boholo surgical simulator software (www.boholo.com). This allowed for the creation of a mirror image of the healthy thumb using the uninjured thumb. Using 3D images of the reconstructed thumb, a model of the big toe and the second toe was created to understand the dimensions of the donor site. This model was also used to repair the donor site defect by designing appropriate iliac bone and superficial circumflex iliac artery flaps. The polylactic acid model of the donor toes and reconstructed thumb was produced using 3D printing. Surgically, the wrap-around flap of the first dorsal metatarsal artery and vein combined with the joint and bone of the second toe was based upon the model donor site. Sensation was reconstructed by anastomosing the dorsal nerve of the foot and the plantar digital nerve of the great toe. Patients commenced exercises 2 weeks after surgery.

RESULTS

All reconstructed thumbs survived, although partial flap necrosis occurred in one case. This was managed with regular dressing changes. Patients were followed up for 3-15 months. The lengths of the reconstructed thumbs are 34-49 mm. The widths of the thumb nail beds are 16-19 mm, and the thickness of the digital pulp is 16-20 mm. The thumb opposition function was 0-1.5 cm; the extension angle was 5°-20° (mean, 16°), and the angle of flexion was 38°-55° (mean, 47°). Two-point discrimination was 9-11 mm (mean, 9.6 mm). The reconstructed thumbs had good appearance, function and sensation. Based on the criteria set forth by the Standard on Approval of Reconstructed Thumb and Finger Functional Assessment of the Chinese Medical Association, the results were considered excellent for four cases and good for one case. The success rate was 100%.

CONCLUSIONS

When planning a wrap-around flap and second toe transplant to reconstruct a thumb, both the donor and recipient sites can be modeled using 3D printing. This can shorten the operative time by supplying digital and accurate schematics for the operation. It can also optimize the function and appearance of the reconstructed thumb while minimizing damage to the donor site.

Vascularized transfer of two coherent toe joints in simultaneously reconstructing MCP and PIP of a mutilated finger

BACKGROUND

The reconstruction of metacarpal- and interphalangeal joints after severe hand injuries has been proven to be challenging. Commonly used procedures like arthrodesis, amputation or ray resection of the finger compromise the functionality of the injured finger. Especially for young patients, the restoration of all functions of the fingers is a priority. Local tissue transfers for finger joint reconstructions is not an option due to inacceptable donor site morbidity; microsurgical tissue transfers in terms of free toe joint transfers have proven to be a valuable method.

METHODS

We present the case of a patient who suffered an excessive injury from a circular saw to his dominant hand. The MCP Joints of D2-D4 were fully destroyed, along with the PIP joint of a subtotally amputated D4. Arteries, nerves and tendons could be coapted directly, while primarily reconstructing of the finger joints was impossible. To ensure a possible regain of full functionality, two coherent joints, the MTP and the PIP of one toe, were transferred to the ring finger as a single transplant, reconstructing the MCP and the PIP joints of the injured finger in a one step procedure. Additionally the MCP joint of the D2 was reconstructed by the use of a free PIP-joint transfer, further the MCP joint of the D3 was replaced by an MCP endoprosthesis.

RESULTS

After a follow up of 3 years the patient displayed full function of his dominant hand including sensitivity, and has gone back to manual work without limitations. The result was cosmetically acceptable and the donor site defect was easily being tolerated by the patient who is playing soccer in the regional soccer league.

CONCLUSION

Free double toe joint transfer has been proven feasible in this patient. While transferring a single toe joint to reconstruct a finger joint is a well-established method, our review of the latest literature showed no case of a free transfer of two coherent joints and three transplanted joints in one hand. The applied microsurgical technique should be considered by microsurgically trained hand surgeons for the treatment of comparable severe hand injuries. In comparison to the most common procedures described for the repair and reconstruction of severely injured finger joints this method showed superior results.

Treatment of the Secondary Defect on the First Metatarsophalangeal Joint Using the Medial Plantar Hallucal Artery Dorsal Perforator Flap

Injuries or burns to the dorsum of the first metatarsophalangeal (MTP) joint may develop scar formation, resulting in hyperextension contracture. Surgical correction of the deformity often produces a secondary defect. The purpose of this study is to report on the use of the medial plantar hallucal artery dorsal perforator flap for the treatment of such defect. From February 2010 to June 2011, 16 patients were treated. The mean preoperative hyperextension of the first MTP joint was 48 degrees. The mean size of the defects was 3.6 × 6 cm. The mean flap size was 4 × 6.5 cm. The mean pedicle length was 4 cm. All flaps survived completely. Patient follow-up lasted a mean of 14 months. At the final follow-up, the mean hyperextension of the first MTP joint was 9 degrees. After surgery, the mean Foot Function Index improved from 62 to 7. Almost all patients were satisfied with the results. Transferring the medial plantar hallucal artery dorsal perforator flap is a useful and reliable technique for the reconstruction of the secondary defect on the first MTP joint.

Treatment of complex soft-tissue defects at the metacarpophalangeal joint of the thumb using the bilobed second dorsal metacarpal artery-based island flap

BACKGROUND

The purpose of this study is to report on reconstruction of complex soft-tissue defects around the metacarpophalangeal joint of the thumb using a bilobed second dorsal metacarpal artery-based island flap taken from the dorsum of the proximal phalanges of the index and long fingers.

METHODS

From March of 2007 to October of 2009, the bilobed second dorsal metacarpal artery-based island flap was transferred in 13 patients. There were two defects on the metacarpophalangeal joint of the thumb. The mean size of the dorsal defects was 2.4 × 3.2 cm; the mean size of the volar defects was 2.6 × 4.0 cm. The mean size of the flaps taken from the index and long fingers was 2.6 × 3.4 cm and 2.8 × 3.2 cm, respectively. The mean pedicle length was 4.9 cm.

RESULTS

All flaps survived completely. At a mean follow-up of 14 months, the mean active motion arc of the thumb metacarpophalangeal joints was 42 degrees. The motion of the donor fingers was similar to that on the opposite side. The mean values of static two-point discrimination of the donor sites of the index and long fingers were 6 and 7 mm, respectively.

CONCLUSION

Transferring the bilobed second dorsal metacarpal artery-based island flap is a useful and reliable technique for reconstructing complex defects around the metacarpophalangeal joint of the thumb.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic IV.

Toe-to-hand transfer: evolving indications and relevant outcomes

Toe-to-hand transfer is indicated for many types of congenital and traumatic thumb absences. This review will highlight the applications of toe-to-hand transfer and their functional, aesthetic, and psychosocial outcomes. Despite its technical complexity, toe to hand reconstruction techniques can provide an elegant option to restore function for patients with difficult hand disabilities.

Use of a bilobed second dorsal metacarpal artery-based island flap for thumb replantation

PURPOSE

An extensive traumatic defect at the level of the proximal phalanx of the thumb presents difficulty in replantation. We report bilobed second dorsal metacarpal artery-based island flap harvested from both the index and middle fingers for reconstruction of the defect and preservation of the normal thumb length.

METHODS

From March 2004 to October 2008, 15 patients (11 men and 4 women; mean age, 35 y; range, 18 to 55 y) with completely or incompletely amputated thumbs associated with extensive defects in the proximal phalanx had replantation and reconstruction. In all cases, a bilobed second dorsal metacarpal artery-based island flap was used due to the large size of the defect. After flap transfer, anastomoses between the veins of the distal part of the thumb and the flap were performed. At the final follow-up, we assessed the mean active range of motion of the metacarpophalangeal and interphalangeal joints of the thumb and the span of the first web in the thumbs that survived. Active motion of the donor fingers was also assessed.

RESULTS

In this series, 13 thumbs survived and 2 failed. All flaps survived completely. At the mean follow-up of 27 months (range, 24 to 29 mo), the mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32° (range, 15° to 45°) and 31° (range, 0° to 47°), respectively. Full active range of motion was observed in all patients in both the metacarpophalangeal and the proximal interphalangeal joints of the donor index and middle fingers.

CONCLUSIONS

Bilobed second dorsal metacarpal artery-based island flap transfer is a useful and reliable technique for thumb replantation when there is an extensive defect in the proximal phalanx and when a single-digit dorsal metacarpal artery island flap is too small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.